Acute middle ear infections in children: evidence on ways to prevent and treat them

In a blog for anyone interested in preventing and treating acute middle ear infections in children, Sarah Chapman from Cochrane UK looks at the Cochrane evidence on various approaches.

Page updated 20 November 2023

Take-home points

Acute middle ear infections, also called acute otitis media, are common in children and can cause earache, fever and occasionally a perforated ear drum (a hole or tear in your eardrum). They often resolve without treatment within three days. There are things you can do to try to prevent ear infections. Making sure your child has had their pneumococcal vaccine (PCV) and flu vaccine may reduce their risk of infection. Taking Xylitol (birch sugar) probably also reduces the risk of ear in healthy children (although probably won’t help children prone to infection) and probiotics may also help prevent infections. To treat infections, antibiotics can have some small benefits, but they also have unwanted effects (such as vomiting). There is a lack of evidence on the use of painkillers for children with ear infections. Paracetamol or ibuprofen may help reduce pain, but it is unclear how they compare.

Acute middle ear infections, also called acute otitis media, are common in children and can cause earache, fever and occasionally a perforated ear drum (a hole or tear in your eardrum). These infections happen when bacteria from the upper part of the throat go to the middle ear. NHS advice is that you do not always need to see a GP for an ear infection as they often get better on their own within 3 days.

Preventing middle ear infections

 ‘Prevention is better than cure’ – true not just for you and your child but much more widely. Antibiotics are often given to treat middle ear infections, and overuse of antibiotics is a global problem as it makes them less effective (known as ‘antibiotic resistance’).

Guidance from the National Institute for Health and Care Excellence (NICE) says that avoiding exposure to passive smoking, use of dummies, and feeding lying down, can all help reduce the risk of ear infections, along with ensuring children have had a complete course of pneumococcal vaccinations (more about that below).

Here are some things that have been studied as possible ways to prevent middle ear infections in children:


 Pneumococcal vaccine (PCV)

 In the UK this is part of the routine vaccination programme for babies. Pneumococcal bacteria can cause many infections from meningitis to ear infections.

The Cochrane Review Pneumococcal conjugate vaccines for preventing acute otitis media in children (November 2020) brought together the evidence on the effect of pneumococcal vaccines (PCV) in preventing acute ear infections in children under 12. The review authors found:

  • PCV in babies may reduce the risk of acute ear infections caused by pneumococcal bacteria but it’s not clear whether there’s an effect on the risk of acute ear infections from any cause
  • there may be no evidence of a beneficial effect on acute ear infections from any cause when PCV is given to high-risk infants, to infants aged over one year, or to older children with a history of respiratory illness
  • mild local reactions to the vaccine, and fever, were common, while serious unwanted effects were rare

Flu vaccine

Although middle ear infections are caused by bacteria, they are often triggered by a viral infection. The Cochrane Review Influenza vaccines for preventing acute otitis media in infants and children (October 2017) has evidence that in infants and children under six years flu vaccination may slightly reduce the risk of acute middle ear infections. Side effects included an increase in fever, runny nose, and drowsiness. The evidence isn’t high quality, ten of the 11 trials were funded by vaccine manufacturers (a potential source of bias) and there was limited information on safety.


There are lots of health claims made about probiotics. Probiotics are live bacteria and yeasts which are thought to help restore the natural balance of bacteria in your gut after illness and may have other beneficial effects. They’re typically added to yogurts or taken as food supplements. You may see them marketed as ‘good’ or ‘friendly’ bacteria.

The Cochrane Review Probiotics for preventing acute otitis media in children (June 2019) finds that probiotics may prevent acute middle ear infections in children not prone to them, and probably reduces the number of children taking antibiotics for any infections. There may be little or no difference in unwanted effects between children taking probiotics and those taking a placebo.

The review authors say there are still lots of unanswered questions about the use of probiotics to protect children, including about the best type to take, when and how long to take them for, and about safety.


Xylitol, or birch sugar, is found in plums, strawberries, raspberries and rowan berries and is used as a sweetener in chewing gum, sweets, toothpaste and medicines. It doesn’t cause tooth decay. Xylitol has been reported to reduce the growth of some disease-causing bacteria and to reduce the ability of some of these to stick to the passageways of the nose and throat.

The Cochrane Review Xylitol for preventing acute otitis media in children up to 12 years of age (August 2016) has evidence from studies comparing xylitol with placebo or no treatment, mostly in healthy children attending daycare centres (three studies) while the other study looked at children with acute respiratory infections. It suggests that:

  • giving xylitol in any form to healthy children probably reduces the number of children who get acute middle ear infections
  • Xylitol probably doesn’t reduce the number of middle ear infections in children prone to them, or in children with respiratory illnesses
  • there is probably little or no difference between those taking xylitol and those taking a placebo in unwanted effects (abdominal discomfort and rash)

Xylitol can be taken as syrup, chewing gum or lozenges. The review authors note that for children able to chew, xylitol taken in chewing gum seems to be more effective than in syrup form.

Treating acute middle ear infections

 Drugs for pain relief

 Despite recommendations in guidelines on the use of painkillers for children with acute middle ear infections, the authors of a 2023 Cochrane Review on this topic have found that there is not much evidence.

The evidence suggests that paracetamol or ibuprofen may be more effective than placebo in relieving short-term ear pain. But it’s not clear how the two drugs compare, nor how effective they are when combined versus using just paracetamol.

Drugs to treat the infection


In high income countries like the UK, acute middle ear infections mostly resolve without drugs and without complications. Using antibiotics adds to the problem of antibiotic resistance and comes with the risk of unwanted effects for the person taking them, such as vomiting, diarrhoea or rash.

The authors of a Cochrane Review on Antibiotics for acute otitis media in children (November 2023) found that:

  • by 24 hours from the start of treatment, 60% of the children had recovered whether or not they had placebo or antibiotics
  • antibiotics had no effect on pain in the first 24 hours and only a slight effect on pain the following days
  • antibiotics did not reduce the number of children with recurrence of infection or hearing loss at three months
  • antibiotics slightly reduced the number of children with perforation of the eardrum
  • it is unclear whether antibiotics reduced rare complications of ear infection
  • unwanted effects such as vomiting happened more often in children taking antibiotics
  • antibiotics seem to be most useful in children younger than two years old with infection in both ears and in children with both infection and discharge from the ear

Most of the evidence was judged to be high quality and the findings are unlikely to change.


A Cochrane Review on Systemic corticosteroids for acute otitis media in children (March 2018) shows that the effects of corticosteroids given by mouth or injection for acute middle ear infection are uncertain.

Find out more

NHS pages on ear infections

References (pdf)

You can join in the conversation on Twitter with @CochraneUK @SarahChapman30 or leave a comment on the blog.

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Sarah Chapman has nothing to disclose

Acute middle ear infections in children: evidence on ways to prevent and treat them by Sarah Chapman

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

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